Historical note: Chevalier Jackson, an early pioneer in thoracic surgery who initiated his career in Pittsburgh, can be credited with the development of effective bronchoscopic techniques to evaluate and treat central airway pathology. More than 80 years ago, he developed many of the principles of bronchoscopic management that we use today. The instrumentation of his time was primarily a rigid metal tube with an incandescent light source attached.

Until the development of fiberoptic instrumentation only 30 years ago, such rigid bronchoscopic approaches were the only means of assessing airway pathology (Figure 1). Because of the luminal diameter and the rigidity of this bronchoscopic instrumentation, visual diagnosis and biopsies of airway pathology were limited to the major airways.

The development and refinement of fiberoptic flexible bronchoscopes during the last 30 years has done much to limit the need for rigid bronchoscopic approaches. Nevertheless, there are fundamental and specific instances where the rigid bronchoscopic approach continues to have utility. In many instances, both rigid and fiberoptic flexible bronchoscopic techniques are complementary in facilitating the management of the patient's airway pathology. Thoracic surgeons interested in the management of central airway pathology must be well-versed in the indications for and the applications of rigid bronchoscopy.

Indications for rigid bronchoscopy

• Massive hemoptysis

Patients presenting with massive hemoptysis (greater than 600 ml in 24 hours) will often be difficult to accurately evaluate with fiberoptic bronchoscopy alone. General anesthesia is routinely required to perform these rigid bronchoscopic interventions. Control of the airway and expeditious removal of the clot from the airway can be accomplished with large bore suction devices. When necessary, occlusive catheters or direct airway packing can be accomplished directly and accurately through the rigid scope lumen. Fulguration of endobronchial bleeding lesions and electrocoagulation control or direct Nd:YAG laser therapy can be accomplished to control the bleeding.

• Evaluation of the pediatric airway

Although new skinny, fiber flexible bronchoscopic instrumentation is becoming more available for the evaluation of pediatric patients, rigid bronchoscopy remains a primary means of evaluating the airway of small children. The airway can be secured and adequate anesthesia accomplished without fear of hypoxia.

• Foreign body removal

In some circumstances, fiberoptic bronchoscopic snaring of foreign bodies aspirated into the airway is unsuccessful. Conversion to rigid bronchoscopy to retrieve the foreign body is indicated early on when the fiberoptic intervention is going poorly. Persistence with the fiberoptic intervention can only increase airway trauma/ edema, which will make the extraction of the foreign body more difficult.

• Removal of tenacious airway secretions/airway casts

Prolonged pulmonary atelectasis related to retained airway secretions can be a significant problem resulting in significant hypoxia and the risk for pulmonary parenchymal infection. When thick bronchial secretions prohibit the therapeutic outcome of fiberoptic bronchoscopy, a rigid bronchoscopic approach to remove the secretions is warranted to hasten the patient's recovery and avoid potentially life-threatening infection.

• Mechanical fulguration/dilation of obstructing tracheobronchial lesions

In cases of airway obstruction, the rigid bronchoscopy allows for three important factors: safe airway control, diagnoses and therapy (Figure 2). Primary or metastatic malignancies known to involve the central airway can lead to total airway obstruction. 

Similarly, benign scar-related narrowing of the trachea can lead to progressive dyspnea and loss of the airway. The rigid bronchoscopy is often a life-saving approach to secure an adequate airway when such obstructive processes involve the trachea or central bronchi. During debridement with biopsy forceps or tumor ablation with the laser, if bleeding occurs, the rigid system allows high-volume suction, use of electrocautery or use of the laser. As always, the rigid scope permits a safe and controlled airway. The use of large endoscopic forceps, direct fulguration of the obstructing lesion with the bronchoscope tip, and gum-tipped or balloon dilation systems can afford temporary control of the airway obstruction. Simultaneous or delayed laser, stent or endobronchial radiotherapy management of the obstructing lesion is usually necessary. Such management will be discussed in a later section of this newsletter.

Suggested reading

Boyd AD. Chevalier Jackson: the father of American bronchoesophagoscopy. Ann Thorac Surg. 57:502, 1994.

Miller Jr. JI. Rigid bronchoscopy. Chest Surg Clin N Am. 161, May 1996.

Pasaoglu I, et al: Bronchoscopic removal of foreign bodies in children: retrospective analysis of 822 cases. Thorac Cardiovasc Surg. 39:95, 1991.

Kelly SM, Marsh BR. Airway foreign bodies. Chest Surg Clin N Am. 6:253, 1996.